Infection Control in Dentistry -Smile4Dr-1

8/17/2019 Infection Control in Dentistry -Smile4Dr-1

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Advicesheet- dentalbooks-drbassam.blogspot.com

Infection control in dentistry A12

dentalbooks-drbassam.blogspot.com

contents page Introduction 5

Routine procedures 5

Patient perception 5

Acceptance of patients 5

Confidentiality 6

The infected dental health care worker 6

Infection control in dentistry 7

Infection control policy 7

Training in infection control 7 Surgery design 7

Decontamination area 8

Choice of equipment 8

Single use (disposable) items 9

Decontamination of instruments and equipment 9

New reusable instruments 10

The decontamination process 10

Pre-sterilisation cleaning 10

Washer-disinfectors 11

Ultrasonic cleaners 12

Manual cleaning 12 Cleaning dental handpieces 13

Inspection and function testing 13

Sterilisation 13

Dental handpieces 14

Checks, tests and record keeping 14

Instrument packaging and storage 15

Decontamination of impressions, prostheses and appliances 15

Surface decontamination 16

Cleaning protocols 16

Water supplies 16

Dental unit water lines 17

Disposal of waste 17 Blood spillages 18


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contents page

Personal protection 18

Immunisation 18

Hand protection 19

Hand hygiene 19

Gloves 20

Latex allergy 20

Eye protection and face masks 20

Surgery clothing 21

Removing PPE 21

Aerosol and saliva/blood splatter 21

Inoculation injuries 21

Emerging infections 22

Transmissible Spongiform Encephalopathies 22

Meticillin-resistant Staphylococcus aureus (MRSA) 23

Tuberculosis 23

Herpes simplex 23

Pandemic flu 23

Appendices

Appendix 1

HTM 01-05: Decontamination in primary dental care practices 24

Essential quality requirements 24

Essential infection control policies 25

Best practice 25

Example layouts for decontamination areas 26

Appendix 2

Decontamination in Scotland 28


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In April 2009, the Department of Health (England) published HTM 01-05:

Decontamination in primary care dental practice which describes essential and

best practice requirements. A summary of these requirements is given in

Appendix 1 and the full version is available on the Department’s website

(www.dh.gov.uk). This advice sheet incorporates the requirements of the

Department’s guidance. Models of the various policies and protocols that

practices are required to have in place are available on the BDA’s website at

www.bda.org/infectioncontrol.

In Scotland, a number of organisations produce guidance on decontamination

in dental practice, some of which is still being developed. A summary of the

advice produced for practices in Scotland is given in Appendix 2.

Introduction

Routine procedures

Patient perception

Acceptance of patients

Dental practices have a responsibility to adopt safe systems of working with

respect to cross-infection control and decontamination. Those working in

primary dental care must ensure quality decontamination processes are in

place. These can be provided by using modern local decontamination

equipment and quality facilities. External decontamination facilities forreprocessing can be used where they meet the needs of the practice.

Implementing safe and realistic infection control procedures requires the fullcompliance of the whole dental team. Every practice must have acomprehensive written infection control policy which identifies the infection

control procedures to be followed. These procedures should be regularlymonitored during clinical sessions and routinely audited. All members of the

dental team must understand and practise these procedures; regular discussionat practice meetings is recommended.

A thorough medical history should be obtained for all patients at the first visitand updated regularly. Medical history questionnaires alongside direct

questioning and discussion between the dentist and the patient arerecommended. Discussions should be conducted in an environment that

permits the disclosure of sensitive and confidential personal information.Medical history information should be retained as part of the patient's dentalrecords.

The medical history and examination may not identify asymptomatic carriers of

infectious disease and standard precautions must be adopted. This means thatthe same infection control procedures must be used for all patients.

All dental professionals have a duty of care to their patients to ensure adequate

infection control procedures are followed. Failure to employ adequate methodsof cross-infection control may call into question a practitioner’s fitness to

practice.

As a result of frequent media coverage, the public is now far more aware of the

need for dentists to practise good infection control. Displaying an infection

control statement may be appropriate in your practice to help allay patient

anxiety and gain their confidence. It may encourage them to ask questions, so

never be too busy to give an answer. Ensure all the members of your practice

team are confident and competent to answer patients' queries or know who to

refer to when necessary.

Whilst a health professional has the right to accept or refuse to treat a patient, it

is important that the dental profession accepts the responsibility of providing

dental treatment to all members of the community. Dental clinicians have ageneral obligation to provide care to those in need and this should extend to

infected patients who should be offered the same high standard of care

available to any other patient.

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Those with human immunodeficiency viruses (HIV), who are otherwise well,

and carriers of the hepatitis viruses may be treated routinely in primary dental

care settings. In the absence of an inoculation injury (which includes blood-

contaminated splashes to the eyes or mouth), the evidence indicates that the

risk of infection to a dental health care worker during the dental treatment of

HIV-infected individuals is negligible. HIV-infected individuals need a high

standard of dental care when they are asymptomatic to minimise dental

problems. If they subsequently develop Acquired Immune Deficiency Syndrome

(AIDS), the associated medical problems may make it appropriate for them to

be referred for specialist dental advice and care.

It is unethical to refuse dental care to those patients with a potentially infectious

disease on the grounds that it could expose the dental clinician to personal risk.It is also illogical as many undiagnosed carriers of infectious diseases passundetected through practices and clinics every day. If patients are refused

treatment because they are known carriers of an infectious disease, they maynot report their conditions honestly or abandon seeking treatment; both results

are unacceptable. Those who reveal that they are infected are providingprivileged information.

All information disclosed by a patient in the course of medical history taking,

consultation and treatment is confidential. No part of the information obtainedshould ever be disclosed to any third party, including relatives, without the

patient's permission. Dentists are responsible for the security of informationgiven by patients, whether it is written on record cards or held on computer. All

members of the dental team should be aware of the duty of strict confidentialityand seek to ensure it at all times. Practices should have a confidentiality policyin place and contracts of employment for dental staff should include a

statement on the need to maintain confidentiality.

All health care workers have an overriding ethical and legal duty to protect thehealth and safety of their patients and those who carry out exposure-prone

procedures should be immune to or non-infectious for hepatitis B. A dentalclinician who believes he or she may be infected with a blood borne virus, TB

or other infection has an ethical responsibility to obtain medical advice,including any necessary testing. If a clinician is infected, further medical adviceand counselling must be sought. Changes to clinical practice may be required

and may include ceasing or restricting practice, the exclusion of exposure-prone procedures or other modifications. An infected clinician must not rely on

his/her own assessment of the possible risks to their patients. Failure to obtainappropriate advice or act upon the advice given would almost certainly lead tothe practitioner’s fitness to practice being questioned.

Exposure-prone procedures are those invasive procedures where there is a risk

that injury to the worker may result in exposure of the patient's open tissues to

the blood of the worker. These include procedures where the worker's glovedhands may be in contact with sharp instruments, needle tips and sharp tissues(spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely

visible at all times.

A dental professional who employs a dental nurse who is subsequently found tobe infected with a blood borne virus should seek advice from local occupational

health services. A risk assessment must be carried out to consider the risk topatients and the need for the nurse to be redeployed within the practice. Therisk assessment must take into account the duties performed by the dental

nurse and the likelihood that the infection could be transmitted to a patient oranother member of staff. An infected dental nurse must not undertake exposure

prone procedures in order to remove, as far as is possible, the risk of transmittinginfection. There may be employment issues that need to be considered andadvice should be sought from the employment advisers at the BDA.

Confidentiality

The infected dental

health care worker


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Infection

control in

dentistry

Infection control policy

Training in infection

control

Surgery design

Members of the dental team have a duty to ensure that infection control

procedures are followed routinely. The mouth carries a large number of

potentially infective microorganisms; saliva and blood are known vectors of

infection. Most carriers of latent infection are unaware of their condition and it is

important, therefore, that the same infection control routine is adopted for all

patients.

The following recommendations for infection control procedures in routine

primary dental practice are made in light of current knowledge and may be

subject to revision, as further information becomes available.

Every practice must have a comprehensive written infection control policy, which

is tailored to the routines of the individual practice and regularly updated. It

should demonstrate that the practice is working to current recommendations for

all aspects of infection control including personal protection, instrument

decontamination and equipment maintenance. The policy should be kept readily

available so that staff can refer to it when necessary.

Where a practice does not have a washer-disinfector installed and/or does not

have separate decontamination facilities, a written assessment of theimprovements needed to incorporate these together with an implementation

plan (subject to local constraints) should be available.

A model infection control policy can be downloaded from the BDA website at


All dental staff must be aware of the procedures required to prevent the

transmission of infection and should understand why these are necessary.

Regular monitoring of the procedures is essential and the infection control

policy for the practice should be reviewed regularly and updated when

necessary and at least annually.

All new staff must be appropriately trained in infection control procedures prior

to working in the practice. Training should equip staff to understand:

• how infections are transmitted

• the practice policy on decontamination and infection control

• what personal protection is required and when to use it

• what to do in the event of accidents or personal injury.

With regard to decontamination procedures, training records should show that

staff

• have been appropriately trained

• are competent to decontaminate the reusable dental instruments currently inuse

• training is updated for any new instruments introduced into the dental

practice.

Individual records of the training received should be maintained for all staff.

The layout of the surgery, which should be simple and uncluttered, is an

important aspect of infection control. Ideally there should be distinct areas for

the operator and the dental nurse, each with a washbasin, which should have

sensor controlled or elbow/foot-operated mixer taps and dispensers for

antimicrobial hand wash solutions, liquid soap and alcohol hand rub /gel. The

operator's area should have access to the turbines, three-in-one syringe, slowhandpiece, bracket table and operating light. The dental nurse's area should

contain the suction lines, perhaps the three-in-one syringe, curing light, and the

cabinetry containing dental materials.

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The surgery should be ‘zoned’ to identify those areas that are likely to be

contaminated during treatment sessions from those that are unlikely to be

contaminated. Zoning can help to make the decontamination process more

efficient; only the contaminated areas need to be cleaned between patients.

At the end of the clinical session, all surfaces should be cleaned.

Work surfaces should be impervious and easy to clean and joins sealed to

prevent the accumulation of contaminated matter and aid cleaning. Coving

between the work surface and the wall will aid cleaning. Seek advice from the

manufacturer on decontamination products compatible with the worksurface.

The floor covering should be impervious, smooth and easy to clean; seams

should be sealed. Coving between the floor and the wall will aid cleaning.

There is a clear need to maximise the separation of decontamination activities

from clinical work and wherever possible, decontamination should take place in

a room (or rooms) away from the clinical area. Where space and room

availability allow, dentists should plan for this as a matter of priority. The

example layouts given in HTM 01-05 Decontamination in primary care dental

practices (Department of Health, 2009) are reproduced in Appendix 1.

Where instruments are reprocessed in the surgery, the reprocessing area

should be as far from the dental chair as possible. To reduce the risk of

exposure to aerosol, manual washing, using ultrasonic cleaners without a lid

and opening decontamination equipment should not take place when the

patient is in the surgery.

The decontamination area should, preferably, comprise a single run of sealed,

easily cleaned worktops and include:

• a separate hand washing sink

• a setting down area for dirty instruments

• washing and rinsing sinks (or separate bowls within a single sink) adjacent

to the receiving area

• utrasonic cleaner (where used)

• a washer-disinfector (where available)

• an area with task lighting for instrument inspection and function testing.

Where a type B (vacuum) autoclave is used, this area can also be used for

wrapping instruments prior to sterilisation

• autoclave(s)

• an area for setting down sterilised instruments where they can be placed

onto trays for same day use or wrapped for storage (where a type N (non-

vacuum) or type S autoclave is used)

• where possible, air movement should be from clean to dirty areas.

A dirty to clean workflow should be maintained throughout the decontamination

process to minimise the possibility of used instruments coming into contact with

sterilised instruments.

A practice protocol for selecting new equipment will help to ensure that the

purchase is necessary (and that other devices already present in the practice

are not suitable), the equipment will achieve what is necessary and, where

required, can be processed. The protocol will help the practice avoid the

purchasing items which later prove problematic – for example, where the

manufacturer recommends decontamination processes that are not available in

the practice. Some of the aspects to consider are given below.

• What you want the equipment to do – will the equipment selected be fit for

this purpose? Is it compatible with other equipment in the surgery?

• How easy will it be to use and maintain?

Decontamination area

Choice of equipment


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• Is it CE marked (a mandatory requirement to demonstrate compliance with

Medical Devices Regulations)?

• Does the instrument need dismantling before cleaning? Are there

instructions from the manufacturer describing how this can be done?

• Does the instrument have a limited life-cycle specified by the manufacturer?

• What are the manufacturer’s recommendations for cleaning and will they be

achievable in practice? Will the instrument withstand automated washer-

disinfector processes?

• When selecting new hand instruments, avoid difficult to clean serrated

handles and check that hinges are easy to clean.

• What cleaning agents are recommended – do they comply with COSHH and

health and safety requirements? Are these cleaning agents compatible with

the washer-disinfector, ultrasonic cleaner and instruments already in use in

the practice?

• Check with the manufacturer which cleaning agents are recommended for

the dental chair covering and work surfaces to ensure that they can be

regularly decontaminated without deterioration.

• Is steam sterilisation (134 – 137OC for three minutes) appropriate for the

instruments? If another time-temperature range is recommended, can this

be undertaken? • Select foot controlled equipment whenever possible.

• Is training required? Will the manufacturer provide it?

• What are the commissioning and validation requirements of the equipment?

What are the ongoing costs?

• Service response – what is the response time in the event of a breakdown?

Single-use (disposable) items

Whenever feasible, single-use items should be considered as an alternative to

processing reusable items. Where instruments and equipment can be

processed for re-use, manufacturers must provide information on effective

decontamination procedures. Where an instrument cannot be safely

decontaminated for re-use, it is described as ‘single-use’ by the manufacturer

and the packaging will bear the international symbol:

Single-use means that a device can be used on a single patient during one

treatment session and then discarded. It is not intended to be reprocessed and

used again – even on the same patient at a later session. Anyone who

decontaminates and reuses a single-use item bears full responsibility for its

safety and effectiveness.

Where instruments are difficult to clean, single-use alternatives (if available)

should be considered. In dentistry, this includes, but is not limited to, matrix

bands, saliva ejectors, aspirator tips and three-in-one tips. Endodontic reamersand files must be treated as single-use (regardless of the manufacturer’s

recommendation) to reduce the risk of prion transmission in dentistry.

Decontamination

of instruments

and equipment

All instruments contaminated with oral and other body fluids must be thoroughly

cleaned and sterilised after use. The decontamination process (also known as

reprocessing) includes pre-sterilisation cleaning, disinfection, inspection,

sterilisation and storage. Manufacturers are required to provide instructions for

the decontamination of their equipment – these instructions should be followed.

It is worth checking with the manufacturer prior to purchase that the equipment

can be used for the purpose intended and decontaminated by the methods used in the practice.


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New dental instruments should be fully decontaminated before use. Identify

instruments that can withstand automated cleaning processes (washer-

disinfectors and ultrasonic cleaners) and those which require manual cleaning.

Some instruments may require dismantling before cleaning and sterilising. It is

important to follow the manufacturer’s instructions, especially if the new

equipment is unfamiliar to those responsible for its reprocessing.

A systematic approach to the decontamination of instruments after use can helpto ensure that dirty instruments are segregated from clean. The diagram

summarises how the individual stages ideally link together to complete thedecontamination process.

New reusable instruments

The decontamination

process

With a washer- disinfector (WD)

With or without an ultrasonic cleaner

manually

Source: HTM 01-05 Decontamination in primary care dental practices (Department of Health, 2009)

After sterilisation, instruments for immediate use (ie on the same day) can be

put onto individual covered trays. At the end of each patient treatment, all

instruments on the tray (used and unused) must be regarded as contaminated

and reprocessed. At the end of the day, unused trays of instruments should be

reprocessed before use. Keeping to a minimum the instruments put onto trays

at the start of the day will reduce the decontamination workload.

A practice protocol should describe the safe procedures for transferring

contaminated instruments to the decontamination area and for transferring

sterilised instruments to the treatment or storage area.

Instruments for use at a later date should be wrapped to prevent

recontamination during storage:

• non-vacuum autoclave – instruments should be dried after sterilisation,

wrapped/ packaged and used within 21 days

• vacuum autoclaves – pre-wrapped/packaged sterilised instruments should

be used within 30 days

Effective cleaning of instruments before sterilisation will reduce the risk of

transmission of infectious agents. Wherever possible, cleaning should be

undertaken using an automated and validated washer-disinfector in preference

to manual cleaning; a washer-disinfector includes a disinfection stage thatrenders instruments safe for handling and inspection. Manual cleaning should

be considered where the manufacturer’s instructions specify the device is not

compatible with automated processes.

Pre-sterilisation cleaning


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Validation means that a process has been verified, tested and documented

and is consistently reproducible. A summary of the validation, testing and

maintenance requirements is available on the BDA website at

www.bda.org/infectioncontrol. A validated washer-disinfector (and, if possible,

ultrasonic cleaner) demonstrates that instruments and equipment are reliably

and consistently cleaned.

Instruments cleaned as soon as possible after use may be more easily cleaned

than those left for a number of hours before reprocessing. Blood, saline and

iodine are corrosive to stainless steel instruments and will cause pitting and

then rusting if remaining on instruments for any length of time. Where a delay is

anticipated, instruments should be kept moist by immersion in water or an

enzymatic cleaner (following the manufacturer’s recommendations for use) or

the use of a foam spray intended to maintain a moist or humid environment.

Long periods of wet storage should be avoided, however.

Dental materials (especially cements) can harden on instruments so should be

removed from instruments as soon as possible after use to allow effective

cleaning.

Where recommended by the manufacturer, instruments and equipment that

consist of more than one component should be dismantled to allow each part to

be adequately cleaned. Members of the dental team should be trained to

ensure competence in dismantling, cleaning, sterilising and reassembling

instruments and equipment.

Washer-disinfectors

Washer-disinfectors offer the best option for the control and reproducibility of

cleaning with a process that can be validated. Dentists should plan, where

possible, to install a validated washer-disinfector to remove the need for manual

cleaning. There are a number of different models that meet current

requirements. The size, model and type chosen should be considered against

the workload and throughput requirements, together with the availability of

space.

A typical washer-disinfector cycle includes five stages:

1. Flush - removes gross contamination using a water temperature of less that

45OC

2. Wash – removes remaining soil using detergents specified by the

manufacturer

3. Rinse(s) – removes detergents

4. Thermal disinfection – temperature raised for required time: 80OC for 10

minutes or 90OC for 1 minute, for example

5. Drying – heated air removes residual moisture.

The manufacturer’s instructions for use should be followed, including

recommendations for water quality/type, detergents and/or disinfectants and

instrument loading. Staff must be trained how to use it and how to perform daily

tests. Records of training must be maintained.

Washer-disinfectors must be loaded correctly to ensure effective cleaning. This

involves:

• not overloading instrument carriers or overlapping instruments

• opening instrument hinges and joints fully

•

attaching instruments requiring irrigation to the irrigation system correctly,ensuring filters are in place if required (eg for handpieces).

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Washer-disinfector logbooks and records should include cycle parameters and

details of routine testing and maintenance. Automated data-loggers or

interfaced small computer-based recording systems can be used, provided the

records are kept securely and replicated (to guard against fading). Records

should be kept for at least two years.

Ultrasonic cleaners

Evidence supports the use of ultrasonic cleaners as an effective means of

cleaning dental instruments and reduces contact with contaminated

instruments. The cleaner must be maintained according to manufacturer’s

recommendations with quarterly testing to ensure that it is fully functional. The

results of all tests should be recorded.

After use, instruments should be immersed briefly in cold water (with detergent)

to remove visible soiling, taking care to avoid inoculation injuries. A container

with a sealing lid is recommended.

The manufacturer’s instructions for operating the ultrasonic cleaner should be

followed.

Place instruments in a suspended basket and not on the floor of the cleaner

(avoid overloading and overlapping) and fully immerse in the cleaning solution.

Joints and hinges should be fully opened and instruments disassembled where

appropriate before immersion. Set the timer, close the lid and do not open until

the cycle is complete. Drain the basket of instruments and rinse using clean

fresh reverse osmosis (RO) or distilled water to remove residual soil and

detergent. Instruments to be wrapped and sterilised in a vacuum autoclave

must be dried first using a disposable non-linting cloth.

The water/fluid must be changed at the end of the clinical session and more

frequently if it becomes heavily contaminated. At the end of each day, the

ultrasonic cleaner must be emptied, cleaned and left dry.

Manual cleaning

Compared with other cleaning methods, manual cleaning carries a greater risk

of inoculation injury. It is however, important for practices to have the facilities,

documented procedures and trained staff to carry out manual cleaning when

other methods are not appropriate or available.

Manual cleaning, although simple to set up, is difficult to validate as it is not

possible to ensure that it is carried out effectively each time. Where manual

cleaning is necessary, the parameters should be controlled as much as

possible to reduce variability in cleaning. A written procedure should be

available and followed routinely. A model protocol can be downloaded from the

BDA website at www.bda.org/infectioncontrol.

A dirty-to-clean workflow should be maintained throughout. Two sinks are

needed - one for cleaning and one for rinsing with separate areas for setting

down dirty and clean instruments. If there is only sufficient space for one setting

down area, the surface should be cleaned with a water-detergent solution

between stages.

Always use detergents specifically made for the manual cleaning of instruments

and mix with water to the correct concentration and temperature (as specified

by the manufacturer). The temperature should not exceed 45OC. Fully submerge

the items to be cleaned (unless manufacturer recommends otherwise) and

scrub using long-handled brushes. Drain the cleaning water and rinse itemsusing RO or freshly distilled water. Instruments to be wrapped and sterilised in a

vacuum autoclave must be dried first using a disposable non- linting cloth.

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Cleaning dental handpieces

Dental handpieces must be decontaminated after use.

• Where the manufacturer confirms that a handpiece can withstand cleaning

in a washer-disinfector and the washer-disinfector can be adapted to clean

handpieces, this method is preferred.

• Dedicated handpiece-cleaners can be considered where a washer-

disinfector is not recommended.

• Commercial products for decontaminating handpieces can be used where

the product can be shown to reduce the risk of infection transmission or the

process can be validated.

• The manufacturer’s recommendations for lubrication should be followed.

• Separate canisters of lubricant should be used for unclean and cleaned

handpieces.

Inspection and function

testing

Sterilisation

After cleaning, instruments should be inspected for cleanliness and checked for

wear or damage before sterilisation. A magnifying glass with task lighting is

recommended.

•If there is residual contamination, the instrument should be rejected and re-cleaned.

• Working parts should move freely and joints should not stick. The occasional

use of a non-oil-based lubricant may be necessary where hinges are stiff.

• The edges of clamping instruments should meet with no overlap or rough

edges.

• The edges of scissors should meet to the tip and move freely across each

other with no overlap or rough edges.

• All screws on jointed instruments should be tight.

Instruments found to be faulty or damaged should be taken out of use. If they

are to be sent for repair, they should be decontaminated fully (cleaned and

sterilised) and labelled ‘decontaminated’ before dispatch. Equipment that

cannot be sterilised must be thoroughly cleaned and disinfected in accordance

with the manufacturer’s instructions.

Saturated steam under pressure delivered at the highest temperature

compatible with the product is the preferred method for the sterilisation of most

instruments and devices used in the clinical setting. In dentistry, this is usually a

temperature of 134-137OC with a holding time of 3 - 3.5 minutes.

Three types of autoclaves are suitable for use in dentistry:

Type N: passive displacement of air with steam (non-vacuum). Designed for

unwrapped, non-hollow and non-air retentive instruments

Type B (vacuum): designed for hollow, air retentive and packaged loads Type S: designed to reprocess specific loads (determined by the manufacturer).

Effective sterilisation requires steam to contact all surfaces of the instrument.

Instruments must, therefore, be loaded into the chamber to allow free

circulation of steam. This is particularly important when air removal is passive;

air remaining in the chamber will impair or prevent the sterilisation process.

Avoid overloading the autoclave chamber.

Water reservoirs should be filled daily using fresh distilled or reverse osmosis

(RO) water. Autoclave water should be discharged after each cycle but where

this is not possible, the reservoir must be drained at the end of each working

session to reduce the likelihood of a build up of toxins in the water supply. Afterthe final use of the day, the chamber should be drained, cleaned and dried and

left with the door open.


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Dental handpieces

The internal lumen of dental handpieces makes them difficult to clean although a

compatible validated washer-disinfector may produce successful cleaning

results. Furthermore, the presence of lubricant in the lumen means that,

whichever autoclave is used, handpiece sterility is unlikely. Good cleaning and

steam sterilisation will, however, result in a beneficial reduction in contamination

levels and bioburden.

Checks and tests and record keeping

Before use each day:

• Clean the rubber door seal with a clean, damp non-linting cloth

• Check the chamber and shelves for cleanliness and debris

• Fill the reservoir with freshly distilled or RO water

• Turn on the power source.

Daily tests and housekeeping tasks should then be carried out and the results

recorded in the logbook:

•Steam penetration test (vacuum autoclaves only)

• Automatic control test (all autoclaves) to demonstrate that the autoclave is

actually working

• Where required, a warm-up cycle before instruments can be processed.

Records of regular checks must be maintained to demonstrate compliance. An

autoclave that fails to meet any of the test requirements should be withdrawn

from service and advice sought from the manufacturer and/or maintenance

contract.

Autoclaves should be commissioned when first purchased to ensure that they

are appropriately calibrated and functioning correctly. Validation before use by a

Competent Person (Decontamination) or service engineer is needed to

demonstrate that the right conditions for sterilisation are achieved. The

equipment must be properly maintained according to the manufacturer's

instructions and periodically examined by a competent person. A summary of

the validation, testing and maintenance requirements is available on the BDA

website at www.bda.org/infectioncontrol.

The parameters should be monitored for each cycle. Printouts and automated

data loggers or interfaced computer-based recording systems are acceptable

provided the records are kept securely and replicated. Printouts fade within a

short time, so require photocopying. Manual records (where no automatic data

production is available) are acceptable and should document the

temperature/pressure achieved or an absence of failure. Records should be

maintained for at least two years.

The readings should be compared with the recommended values – if any

reading is outside its specified limits, the sterilisation cycle must be regarded as

unsatisfactory, irrespective of the results obtained from chemical indicators and

the autoclave cycle checked again. If the second cycle is unsatisfactory, the

autoclave should not be used until the problem has been rectified by an

appropriately trained engineer. Chemical indicators (TST strips, for example)

demonstrate only that instruments have been through a sterilisation cycle, not

that they have been sterilised



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Instrument packaging and

storage

Decontamination of

impressions, prostheses

and appliances

Sterilised instruments must be protected against the possibility of

recontamination by wrapping or storing in a covered container. The autoclave

used affects the wrapping and storing options.

Type B autoclave (vacuum): dried instruments can be pre-wrapped. Once

sterilised, the instruments may be stored for up to 30 days.

Type N autoclave (displacement): dried instruments can only be wrapped

after sterilisation using sealed view packs. If trays of instruments are to be

stored, the entire tray should be placed in a sealed pack. Instruments can be

stored for up to 21 days. Alternatively, instruments can be covered and used

within the current session.

Type S autoclaves : the manufacturer’s guidance for pre-wrapping should be

followed although post-sterilisation packing remains an option.

Disposable non-linting cloths should be used to dry instruments and disposed

of after each sterilisation load.

The area where sterilised instruments are packaged for storage should be freeof clutter and wiped clean with detergent and alcohol wipes at the start of each

session.

Instruments should be stored in an area dedicated for the purpose and away

from direct sunlight and water in a secure, dry and cool environment. Where

this is in the surgery, the storage area should be as far from the dental chair as

reasonably practicable; a purpose designed storage cabinet that can be easily

cleaned will be useful. Ideally, air flow should be from clean to dirty areas.

Where possible, practices should plan to store instruments in a separate

environment, away from the surgery.

Storage systems must ensure easy identification of instruments and monitoring

of storage times to ensure recommended intervals are not exceeded. The

packaging should therefore display the use-by date and a system of first-in,

first-out introduced. Simple record keeping for infrequently used instruments will

help to avoid excessive periods of storage resulting in pathogen recolonisation.

The record should show the date of decontamination and an expiry date.

Before use, check that the packaging is intact or the instruments have remained

covered, the sterilisation indicator confirms that the pack has been sterilised (if

a type B autoclave has been used) and visible contamination is absent.

The responsibility for ensuring these devices have been cleaned and disinfected

prior to dispatch to the laboratory lies solely with the dentist. It is good practice

to agree the cleaning and disinfection process with the laboratory and label thedevice to indicate disinfected status. This removes uncertainty and, for

impressions, also removes the possibility of repeated disinfection,

which may detract from quality.

Immediately on removal from the mouth, the device should be rinsed under

running water to remove saliva, blood and debris. Continue the process until it

is visibly clean. If an appliance or prosthesis is grossly contaminated, it should

be cleaned in an ultrasonic bath containing detergent and then rinsed.

The device should then be disinfected following the manufacturer's

recommendations. Products that are suitable for the disinfection of impressions,

prostheses or appliances are CE marked to demonstrate conformity toEuropean Directives.


15/29


There are two methods of disinfection: immersion and dipping.

Immersion in disinfectant (following the manufacturer’s recommendations for

dilution and duration) can be effective but may be compromised by the limited

working life of the disinfectant, which is affected by the frequency of use and

the presence of biological debris.

Dipping avoids the prolonged immersion that can distort hydrocolloid and

polyether impression materials. The recommended contact time is still

necessary, during which the impression must not be allowed to dry out.

Following disinfection, the device must be thoroughly rinsed in water before

packaging to send to the laboratory with a confirmation that it has been

disinfected. Items received from a laboratory should also be disinfected.

Surfaces should be impervious and easily cleanable. Work surfaces and floor

coverings should be continuous, non-slip and, where possible, without joints. If

present, joints should be sealed. Coving between the floor and wall will help

prevent accumulation of dust and dirt. The manufacturer’s advice should be

sought on the compatibility of detergents and disinfectants with the surface orequipment.

The practice should have a written protocol outlining surface- and room-

cleaning schedules and maintain simple records. Cleaning staff should be

briefed on cleaning patient care areas and decontamination rooms.

Surfaces can be effectively cleaned using commercial bactericidal cleaning

agents and wipes. Alcohol, although effective against viruses, binds to blood

protein and stainless steel; it should therefore be avoided. Water with suitable

detergents is satisfactory, provided the surface is dried after cleaning. Following

initial deep cleaning of a surface, subsequent use of a wet or dry microfibre

cloth can achieve satisfactory removal of infectious agents. The mircrofibre can

then be reprocessed as laundry at the end of each session or when obviously

contaminated.

A strict system of zoning aids and simplifies the cleaning process. In practice,

this means defining the areas, which will become heavily contaminated during

operative procedures – worksurfaces, dental chair, curing lamp, inspection light,

hand controls, spittoons, and aspirator, for example. Light and chair hand

controls can be protected with disposable impervious coverings and changed

between patients. If these are not used, the controls must be cleaned effectively

between patients.

At the end of clinical sessions, all work surfaces, including those apparently

uncontaminated, should be thoroughly cleaned using disposable cloths ormicrofibre materials and should include the taps, drainage points, splashbacks,

cupboard doors and sinks. Aspirators, drains and spittoons should be cleaned

at the end of a session according to manufacturers’ instructions.

Computer keyboards should be either washable or provided with covers that

can be easily decontaminated at frequent intervals.

Practices should have a written scheme (a course of action) for controlling

Legionella bacteria in water systems and preventing or controlling the risk. A

risk assessment will identify potential problems in the system (for example,

excess storage capacity, temperature distribution problems, low water usage,

inappropriate materials etc). Further information is available on the BDA’swebsite (www.bda.org).

Surface decontamination

Cleaning protocols

Water supplies


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Dental unit water lines (DUWLs)

The majority of dental units will harbour biofilm, a source of microbial

contamination for the water produced by the unit, so the water will not be

potable (ie of drinking water quality). Contaminated water is a potential hazard

to both patients and surgery staff and may harbour potentially pathogenic

organisms such as Legionella spp and Pseudomonas aeruginosa.

All water lines should be fitted with anti-retraction valves to help prevent

contamination of the lines but these valves cannot be relied upon to prevent

infected material being aspirated back into the system. DUWLs should be

flushed for at least two minutes at the beginning of the day and for at least

20-30 seconds between patients to reduce the microbiological counts in the

water delivery tube.

No currently available single method or device will completely eliminate

biocontamination of DUWLs or exclude the risk of cross-contamination. The

manufacturer’s instructions should be followed for the periodic disinfection of

water lines. Introducing chemical treatments into the dental unit is best achieved

via a water reservoir (bottled water system), which can be fitted retrospectively,

if not fitted at the time of purchase. The water bottles should be removed,flushed with distilled or RO water, left to dry overnight and stored inverted.

An effective treatment regime includes an initial purge to remove longstanding

biofilm followed by a daily maintenance regime to prevent the reformation of

fresh biofilm. Waterline biofilm reforms rapidly if the unit remains untreated, so

less frequent intermittent treatments may fail. For surgical procedures, an

independent system with a sterile irrigant should be used.

Manufacturers of dental units should supply guidance for the maintenance of

the unit and treatment regimes to ensure water quality. A simple dipslide culture

test allows practices to assess the effectiveness of the treatment regime. This

test involves a plastic slide coated with an agar culture medium dipped into a

sample of water from the dental unit and incubated in a sealed container at

room temperature for seven days, at which stage bacterial colonies will be

visible to the naked eye. A guide on counting the bacterial colonies should be

supplied with the dipslide test. Providers of biofilm treatment systems will often

offer this service as part of their package.

The design of some dental equipment requiring a mains water supply means

that it is possible for contaminated water to be drawn back through the

waterlines to the mains water supply (backflow/backsiphonage). This can affect

the dental unit, wet-line suction pumps, automatic radiographic processors and

washer-disinfectors. Interrupting the water supply to the surgery by a physical

break (air gap) will remove the possibility of backflow. Some equipment

requiring a water supply is now manufactured to incorporate an air gap - checkthis with the manufacturer.

Disposal of waste All waste in the practice must be:

• correctly segregated

• stored safely and securely on the premises

• packaged appropriately for transport

• described accurately and fully on the accompanying documentation when

removed

• transferred to an Authorised Person for transport to an authorised waste site

• appropriately registered, with necessary records and returns at the practice.

Dental practices produce a range of hazardous and non-hazardous waste.

Further information can be found in the BDA Advice Note Management of

healthcare waste available at www.bda.org/infectioncontrol.



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If blood is spilled, the spillage should be dealt with as soon as possible following

a protocol that protects against infection. The spilled blood should be completely

covered either by disposable towels, which are then treated with sodium

hypochlorite solution or sodium dichloroisocyanurate granules, both

producing10,000 ppm chlorine. Good ventilation is essential. Allow at least 5

minutes to elapse before clearing and disposing of towels as clinical waste. The

dental health care worker dealing with the spillage must wear appropriate

protective clothing: household gloves, protective eyewear, a disposable apron

and, in the case of an extensive floor spillage, protective footwear.

The employer has a duty of care towards employees to provide a safe place of

work. It is not sufficient simply to provide personal protective equipment such

as gloves and eye protection; the employer must ensure that it is being used in

the correct manner. It is important that all staff understand the principles of

personal protection and that compliance is part of their contracts of

employment.

Advice should be sought from the local occupational health department on theappropriate vaccination requirements of all clinical staff. All those involved in

clinical procedures must be vaccinated against hepatitis B. If an inoculation

injury is sustained before completion of the course, follow up action, including

boosters and tests for hepatitis B markers, is essential. The hepatitis B vaccine

is effective in preventing infection in individuals who produce specific antibodies

to the hepatitis B surface antigen (anti-HBs). Antibody responses to the

hepatitis B vaccine vary widely between individuals. It is preferable to achieve

anti-HBs levels of above 100mIU/ml, although levels of 10mIU/ml or more are

generally accepted as enough to protect against infection. Protection against

infection is maintained even if antibody concentrations at the time of exposure

have declined. Antibody titres should be checked one to four months after

completion of a primary course of the vaccine.

Responders with anti-HBs levels ≥100mIU/ml do not require any further primary

doses; once a response has been established further assessment of antibody

levels is not indicated. A single booster dose at around five years after primary

vaccination is recommended for all health care workers who have contact with

blood, blood stained fluids and patients' tissues. Pre- and post-testing at the

time of this booster is not required if the individual responded to the primary

course of vaccine.

Responders with anti-HBs levels of 10 to 100mIU/ml should receive one

additional dose of vaccine at the time; further assessment of antibody levels is

not indicated. They should also receive the booster at five years.

An antibody level below 10mIU/ml is classified as a non-response to the

vaccine and testing for markers of current or past infection is required (and to

exclude the possibility of being a carrier of infection). Those identified as non-

responders should undergo a repeat course of vaccine, followed by retesting

one to four months after the second course. Those who still have anti-HBs

levels below 10mIU/ml and who have no markers of current or past infection,

will require hepatitis B immunoglobulin for protection if exposed to the virus.

Employers must hold documentary evidence to demonstrate that all relevant

members of the dental team have been immunised and their responses to the

vaccine checked; post vaccination blood test results will show whether an

adequate level of immunity has been achieved. The consent of the employeemust be obtained before the occupational health department or the GMP is

approached. Any information provided is confidential and should be stored

appropriately.

Blood spillages

Personal

protection

Immunisation


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New staff who are not immunised should undergo a course of vaccination as

soon as possible. Chairside assisting can begin after the first vaccination as

long as a risk assessment of their duties has been carried out, and the

appropriate controls identified have been put in place.

Further information is available in BDA Advice Note Immunisation against

hepatitis B available at www.bda.org./infectioncontrol.

Hand protection Hand care is vital to infection control; lacerated, abraded and cracked skin can

offer a portal of entry for microorganisms. Clean hands complement the use of

gloves; neither is a substitute for the other. Training in hand hygiene should be

included in a staff induction programme and regular update training provided to

all staff.

Hand hygiene

There are different levels of hand hygiene depending on the potential for

contamination of the hands and the process to be undertaken.

Social (10-15 seconds) will remove transient microorganisms using plain or

antimicrobial liquid soap. When: general non-clinical activities, including decontamination.

Hygienic (15-30 seconds) will destroy microorganisms and provide a residual

effect using an antiseptic cleanser or antimicrobial soap from a dispenser.

When: before wearing gloves to carry out clinical procedures and after contact

with blood and other body fluids.

Surgical scrub (2-3 minutes, ensuring all areas of the hands and forearms

are covered) will substantially reduce the numbers of resident microorganismsusing an antiseptic hand cleaner (chlorhexidine gluconate 4%, povidone iodine 7.5%).

When: oral, periodontal and implant surgery

A poster depicting the relevant method(s) should be displayed above everywash-hand basin in the practice. A poster is included in the Department of

Health’s guidance (HTM 01-05) and is also available on the BDA website atwww.bda.org/infectioncontrol.

To reduce the risk of irritation, mild liquid soap should be applied to wet handsand hands washed under running water. Hands should be washed:

• Before and after each treatment session

• Before and after the removal of PPE

• Following the washing of dental instruments

• Before contact with sterilised instruments (wrapped and unwrapped)

• After cleaning or maintaining decontamination devices used on dental

instruments

• At the completion of decontamination work.

After washing, hands should be dried thoroughly, using disposable towels, toprevent transfer of microorganisms and prevent skin damage. Hand cream

(preferably water-based) will help to avoid chapped or cracking skin. A wall-mounted dispenser with disposable cartridges should be used.

Fingernails should be kept clean, short and smooth. False nails and nail polishshould not be used. Rings, bracelets and wrist watches should not be worn

during clinical procedures. If a wedding ring is worn, the skin beneath it shouldbe washed and dried thoroughly.

Further information is available in the BDA’s model policy on hand hygiene,

available on the BDA website at www.bda.org/infectioncontrol.

http://www.bda.org./infectioncontrolhttp://www.bda.org./infectioncontrolhttp://www.bda.org./infectioncontrolhttp://www.bda.org./infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org./infectioncontrol


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20 -dentalbooks-drbassam.blogspot.com

Gloves

Gloves must be worn for all clinical procedures and treated as single use items,

so a new pair of gloves must be used for each patient. It is important that

gloves fit properly. Gloves should be put on immediately before contact with the

patient and removed as soon as clinical treatment is complete. Used gloves

must be disposed of as clinical waste.

There is a variety of gloves available for clinical procedures. Those selected

should be –

• good quality non-sterile medical gloves (to European standard BSEN 455,

parts 1 and 2, medical gloves for single use), worn for all clinical procedures

and changed after every patient

• well fitting and non-powdered. The powder from gloves can contaminate

veneers and radiographs, disperse allergenic proteins into the surgery

atmosphere and interfere with wound healing

• low in extractable proteins (


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Surgery clothing

Removing PPE

Aerosol and saliva/blood

splatter

Inoculation injuries

A wide variety of clothing is worn in dental surgeries and in many practices is

used to reinforce the corporate image. Surgery clothing should not be worn

outside the practice; adequate changing and storage facilities must be

provided. Short sleeves allow the forearms to be washed as part of the

handwashing routine. Long sleeves are more likely to become contaminated

during clinical sessions and could cause a breach in infection control.

Surgery clothing can become contaminated with microorganisms during

procedures, so freshly laundered uniforms should be worn every day. Machine-

washing with a suitable detergent at a minimum temperature of 60OC will

reduce any potential microbial contamination.

Disposable plastic aprons should be worn during decontamination processes.

Depending on the type of PPE worn, it should be removed in the following

order:

1. Gloves – ensuring that the gloves end up inside out and that the hands do

not become contaminated. If contaminated, wash hands thoroughly before

removing other PPE. 2. Plastic disposable apron – by breaking the neck straps and gathering the

apron together touching the inside only.

3. Face mask – by breaking the straps of lifting over the ears, avoiding

touching the outer surface of the mask. Never allow mask to hang around

neck.

4. Face and eye protection, taking care not to touch outer surfaces.

5. Wash hands thoroughly.

Good surgery ventilation and efficient high-volume aspirators, which exhaust

externally from the premises, will reduce the risk of infection by dispersing and

eliminating aerosols. High-volume aspirators turned on prior to the handpiece

will reduce risk from aerosols. External vents should discharge without risk to

the public or re-circulation into any building. Aspirators and tubing should be

cleaned and disinfected regularly in accordance with the manufacturer's

instructions and the system should be flushed through at the end of each

session with their recommended surfactant/detergent and/or non-foaming

disinfecting agent.

Rubber dam isolation of teeth also offers substantial advantages and should be

used whenever practicable. It enhances the quality of the operative

environment and virtually abolishes saliva/blood splatter. When working without

rubber dam, the use of high-volume aspiration is essential.

Inoculation injuries are the most likely route for transmission of blood borne

viral infections in dentistry. The definition of an inoculation injury includes allincidents where a contaminated object or substance breaches the integrity of

the skin or mucous membranes or comes into contact with the eyes. The

following are typical examples:

• sticking or stabbing with a used needle or other instrument

• splashes with a contaminated substance to the eye or other open lesion

• cuts with contaminated equipment

• bites or scratches inflicted by patients.

Inoculation injuries must be dealt with promptly and correctly.

•

Allow the wound to bleed and then wash thoroughly with running water.


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• Assess the risks associated with the patient and the injury. Where there is

reason to be concerned about the possible transmission of infection, the

injured person should seek urgent advice according to the local

arrangements in place on what follow up action, including serological

surveillance, is necessary. All practices should have formal links with their

local occupational health service, so that management of sharps injuries is

undertaken promptly and according to accepted national protocols.

• Contact the occupational health service of the primary care organisation for

advice on post-exposure prophylaxis. Practices without an NHS contract

may have to arrange this privately. Every practice should have details of the

local contact displayed prominently.

• When local advice is not available, advice should be obtained from the

following sources:

England: Health Protection Agency Centre for Infections 61 Colindale Avenue, London NW9 5EQ

Tel: 020 8200 4400, Email: [email protected]

Scotland: Health Protection Scotland

Clifton House, Clifton Place, Glasgow G3 7LN Tel: 0141 300 1100, Email: [email protected]

Wales: PHL Cardiff

University Hospital of Wales, Heath Park, Cardiff CF14 4XWTel: 02920 742718

N Ireland: Director of Public Health at the local Health and Social

Services Board

• Make a full record of the incident in the accident book, including details of

who was injured, how the incident occurred, what action was taken, which

dentists were informed and when and, if known, the name of the patient

being treated. Both the injured person and the dentist in charge shouldcountersign the record.

In dentistry, the risk of acquiring HIV infection following an inoculation injury is

very low. If, however, the injury is risk-assessed as significant for transmission

of HIV and the source patient is HIV infected, post exposure prophylaxis (PEP)

should be commenced as soon as possible after the incident and ideally within

the hour. PEP involves the use of a short course (four weeks) of treatment with

anti-retroviral drugs in an attempt to reduce even further the risk of infection

with HIV following exposure. Dentists should clarify with their local occupational

health service the local arrangements for urgent access to PEP before any

incident occurs.

CJD and related conditions raise new infection control questions: 'prions', the

infectious agents that cause them, are much more difficult to destroy than

conventional micro-organisms, so optimal decontamination standards need to

be observed. All instruments must be thoroughly cleaned before autoclaving, in

order to remove as much matter as possible. Patients with vCJD or CJD, or

identified as ‘at-risk’ of vCJD for public health purposes, (or their relatives)

should not be refused routine dental treatment.

Guidance on the prevention of transmission is available in Transmissible

Spongiform Encephalopathy Agents: safe working and the prevention of

infection produced by the Advisory Committee on Dangerous Pathogens(December 2003) and supplemented by a letter from the Chief Dental Officer

(February 2005). Both are available on the Department of Health and BDA

websites.

Emerging

infections

Transmissible Spongiform

Encephalopathies

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Meticillin-resistant

Staphylococcus aureus

(MRSA)

Tuberculosis

Herpes simplex

Pandemic flu

No additional infection control precautions are necessary for the dental

treatment of patients colonised with MRSA. However, members of the dental

team known to be colonised with MRSA should not undertake or assist with

invasive procedures. A clinical microbiologist or communicable disease

physician will be able to provide treatment to eradicate the MRSA colonisation.

The incidence of all forms of tuberculosis (TB) is rising and now approximately

one third of the world's population is infected. The disease is spread by droplets

or by direct contact and has been transmitted by dental procedures. Although

Mycobacterium tuberculosis is the usual cause of TB, other species of

mycobacterium can also cause the disease. The infection control procedures

described in this document should be adequate protection against transmission

of TB. Staff infected with TB should seek guidance from their local occupational

health services.

Herpes simplex virus type 1 (HSV-1) is usually associated with infections of the

lips, mouth and face. It is the most common virus and is usually associated with

childhood. HSV-1 often causes lesions inside the mouth such as cold sores and

is transmitted by contact with infected saliva. By adulthood, up to 90% of

individuals will have antibodies to HSV-1. The herpes virus can reside in thebody for years, appearing only as a cold sore when something provokes it, for

example, illness, stress, hormonal changes and sun exposure. Individuals

usually experience a tenderness, tingling or burning before the actual sore

appears, initially as a blister which subsequently crusts over.

During the prodromal stage and active stage with open lesions, the individual is

shedding large amounts of the virus. Ideally, dental treatment should not be

undertaken but the decision lies with the individual clinician bearing in mind that

• the herpes simplex virus is highly infectious and easily transmitted

• manipulation of the facial and oral tissues can exacerbate the condition and

cause breakdown of the lesion and bleeding

• spread of the virus to other areas of the skin can cause significant problems

(new primary lesions, for example); infection of the eyes is a rare but

significantly serious complication.

A patient requiring urgent dental care should not be denied it but until the

herpetic lesions are healed, the dental team should take care to prevent the

spread of the virus.

The Department of Health has issued specific guidance for dental practices on

what to do in the event of pandemic flu, which is available at

www.dh.gov.uk/en/Publichealth/Flu and summarised on the BDA’s website at


Influenza is a respiratory illness characterised by rapid onset of a wide range of

symptoms including fever, cough, headache, sore throat and aching muscles

and joints. It has an average incubation time of two to three days and people

are most infectious soon after they develop symptoms.

Transmission is through close contact with an infected coughing or sneezing

person. Hand washing (with soap and water or alcohol handrub) and

environmental cleaning will deactivate the virus and help control spread through

contact.

The main measures for containing the infection include

• standard infection control measures and droplet precautions

• a ‘stay at home’ approach for anyone with flu-like symptoms

http://www.dh.gov.uk/en/Publichealth/Fluhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.bda.org/infectioncontrolhttp://www.dh.gov.uk/en/Publichealth/Flu


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• separating flu-infected patients from well patients when dental care is

needed

• preventing symptomatic visitors (accompanying well patients, for example)

from attending the practice.

HTM 01-05: Decontamination in primary dental care practices

Published by the Department of Health in 2009, the guidance HTM 01-05 is

based on a principle of continuous improvement and introduces benchmarks to

achieve compliance with ‘essential quality requirements’ and ‘best practice’.

Essential requirements should be in place within 12 months of publication.

There is no timescale for implementing best practice, but practices should plan

how to progress towards it where they can, identifying when they might have

separate decontamination facilities incorporating a washer-disinfector. The

guidance recognises, however, that it will take some practices longer than

others to comply and some may never comply fully.

Where new practices are commissioned or new premises contemplated, bestpractice requirements should be adopted wherever reasonably practicable.

Essential quality requirements

Prior to sterilisation, cleaned instruments should be free of visible contaminants

when inspected. Reprocessing using a validated decontamination process,

which includes a cleaning and steam sterilisation (using a validated autoclave),

should provide instruments in a sterilised state at the end of the reprocessing

cycle. Reprocessed instruments should be stored in a way to prevent

microbiological recolonisation. Decontamination processes should be audited

quarterly.

In maintaining and developing decontamination practices, the following should

be included:

• a local infection control policy, updated as necessary

• protocol for decontaminating instruments (as part of the infection control

policy)

• storage, preparation and use of decontamination products in line with

COSHH Regulations

• procedures for management of single-use and re-usable instruments

• reprocessing of instrument using dedicated equipment

• dedicated handwashing facilities

• instrument cleaning using an ultrasonic bath and or manual cleaning and

inspected to ensure free from visible contamination. Practices should plan

for the introduction of washer-disinfectors • separation of instrument processing from other clinical work by physical or

temporal means – the designated area for decontamination may be in or

adjacent to a clinical room

• decontamination equipment should be fit for purpose and validated – it

should be commissioned, maintained and periodically tested by a

Competent Person (decontamination), with records of maintenance kept and

functioning monitored and recorded

• appropriate and controlled disposal of waste

• a documented training protocol with individual training records for all staff

involved with decontamination

• an assessment of changes needed to progress to best practice

•

immunisation against hepatitis B for all staff involved in decontamination (and tetanus, if local policies require)

Appendix 1


24/29


• plan to use washer-disinfectors to clean and disinfect handpieces or use

dedicated cleaning equipment

• two dedicated sinks for decontamination (in addition to the dedicated sink(s)

for handwashing)

• routine (quarterly) audits of infection control requirements (in line with HTM

01-05); use of the audit tool produced by the Infection Prevention Society is

recommended

Essential infection control policies

Having the correct documentation is key to the essential quality requirements.

All practices should have an infection control policy together with the policies

and procedures listed below. Models of these policies and procdures are

available on the BDA website at www.bda.org/infectioncontrol.

• Minimising the risk of blood-borne virus transmission, including needlestick

injuries (policy)

• Decontamination and storage of dental instruments (policy)

• Cleaning, disinfection and sterilisation of dental instruments (procedures)

• Clinical waste disposal (policy)

•Hand hygiene (policy)

• Decontamination of new reusable instruments (policy)

• Personal protective equipment use (procedures)

• Management of dental instruments and equipment in infection control

(procedures)

• The use, storage and disposal of disinfectants within the practice (procedures)

• Spillage procedures (as part of COSHH)

• Environmental cleaning and maintenance (policy)

• Transfer of contaminated items from the treatment to decontamination area

(procedures)

• A documented training scheme with individual training records for all staff

engaged in decontamination.

Systems should be developed to ensure instruments sterilised in a non-vacuum

autoclave are used immediately or, if wrapped after sterilisation, within 21 days.

Instruments wrapped and sterilised in a vacuum autoclaves should be used

within 30 days.

Best practice

Best practice is concerned with achieving higher standards in infection control

through improvements in premises and equipment, and changes in practice

management and the culture in which patients are treated by the dental team.

The Department of Health has not set timescales for achieving best practice,

recognising that it will take some practices longer than others and that some

may never be able to comply fully. Some PCTs, however, are implementing

local timescales for complying with best practice requirements; NHS practicesshould, therefore, be aware of local policies for achieving best practice.

Best practice requirements include:

• Installing a modern validated washer-disinfector of adequate capacity to

remove the need for manual washing.

• The use of a decontamination room or rooms to provide more complete

separation from other work activities, enhancing the distinction between

clean and dirty workflows. Access should be restricted to those staff

performing decontamination duties.

• Suitable instrument storage away from the surgery to reduce exposure to air

and possible pathogenic contamination. Systems should ensure instrumentsare easily identified for selection and are used on a first-in, first-out principle

within the recommended time frames.



25/29


Example layouts for decontamination areas

Single decontamination room, no washer-disinfector

Source: HTM 01-05 Decontamination in primary dental practices. Department of Health 2009

Single decontamination room, with washer-disinfector



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Two decontamination rooms, with washer-disinfector



27/29


Decontamination in Scotland

A number of organisations provide useful guidance on compliance with

decontamination standards in Scotland. The following guidance on

decontamination in dentistry can be found at www.scottishdental.org.

SDCEP Decontamination into Practice

The Scottish Dental Clinical Effectiveness Programme (SDCEP) is an initiative

of the National Dental Advisory Committee (NDAC) and is supported by the

Scottish Executive and NHS Education for Scotland.

The Programme aims to provide user-friendly, evidence-based guidance for the

dental profession in Scotland. SDCEP guidance is designed to help the dental

team provide improved care for patients by bringing together the best available

information and presenting it in a user-friendly way.

Decontamination into practice is a series of documents providng advice on

instrument decontamination. The first part of the series Cleaning of dental

instruments was published in March 2007 and can be downloaded from the

SDCEP website at www.sdcep.org.uk. An introduction to the series andappendices that provide additional advice are also available to download. The

second part of the series Sterilisation of dental instruments is in development.

Health Protection Scotland

The Scottish Health Planning Note 13 Part 2 Decontamination facilities: Local

decontamination units provides guidance on planning and designing an LDU

using three models:

• two room local decontamination unit with ante rooms

• two room local decontamination unit

• single room local decontamination unit.

Planning Note 13 Part 2 is available at www.scottishdental.org.

Chief Dental Officer Letters

Various CDO letters provide useful information on dental decontamination and

capital funding for NHS practices. The following are available at

www.scottishdental.org

• Capital funding to support practice improvements in decontamination of

instruments in dental primary care (CDO letter dated September 2008)

• Decontamination of instruments in dental primary care (CDO letter 1 dated

2007) • Decontamination for primary care dental services (CDO letter 2 dated 2007)

The National Procurement contr act

NHS Scotland National Procurement has established a national contract

(MEK005) for the provision of local decontamination equipment (ie autoclaves,

washer disinfectors and ultrasonic cleaners). The contract includes the

provision of equipment and its installation, commissioning, validation, periodic

testing and maintenance.

The decision as to which equipment is available on the new contract, and

therefore recommended to practitioners, is based on the outcome of a tenderevaluation process. The evaluation process includes a number of factors

including whether the equipment meets the technical requirements, the level of

after sales support and the cost.

Appendix 2

http://www.scottishdental.org/http://www.scottishdental.org/http://www.sdcep.org.uk/http://www.scottishdental.org/http://www.scottishdental.org/http://www.scottishdental.org/http://www.scottishdental.org/http://www.scottishdental.org/http://www.scottishdental.org/http://www.sdcep.org.uk/http://www.scottishdental.org/


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The MEK005 contract is revised and published on an annual basis. The list of

currently approved decontamination equipment and a guide on how to access

the contract is available at www.scottishdental.org

Dental Decontamination Work ing Group

The Scottish Dental Decontamination Working Group was formed in 2008 and

includes representatives from the Scottish Government, the BDA and members

of the dental profession. Its remit includes:

• fully establishing and quantifying the extent of the issues facing NHS Boards

and their independent contractors and setting a baseline position

• exploring with NHS Boards the risk assessments and service development

plans which are in place to support compliance with decontamination and

sterilisation requirements in dental practice

• ensuring coherence across the work of Health Protection Scotland, NHS

Education Scotland, Healthcare Facilities Scotland, National Procurement

and NHS Boards in the provision of advice and support to NHS Boards and

practices, and to ensure the development of strategic solutions

•developing an action plan which sets realistic and achievable timescalesunderpinned by risk assessment and which reflects the complexities of

emerging technology and scientific research.

http://www.scottishdental.org/http://www.scottishdental.org/http://www.scottishdental.org/


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1ll)A' dvice

British Dental Association

64 Wimpole Str eet London W1G 8YS Tel: 020 7563 4563 Fax: 020 7487 5232

E-mail: [email protected] www.bda.org © BDA May 2009
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